Last Responders — Coroners, Funeral Workers and Others — Say They Faced Risks as COVID Spread

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Stephanie Simon, an embalmer at Rhodes Funeral Home in New Orleans, in a still from the 2021 documentary "Death Is Our Business." Funeral workers and other last responders say they faced risks as COVID-19 spread.

Stephanie Simon, an embalmer at Rhodes Funeral Home in New Orleans, in a still from the 2021 documentary "Death Is Our Business." Funeral workers and other last responders say they faced risks as COVID-19 spread.

June 17, 2021

Editor’s note: The following story contains descriptions of postmortem procedures.

The first body arrived on a mild Saturday in March 2020. Stephanie Simon, an embalmer at Rhodes Funeral Home in New Orleans, had been dreading the day since hearing of the deadly, flulike virus that had landed on the East and West Coasts.

Simon proceeded with the embalming process. But this time something was different. “The blood clots were tremendous, unlike what I had ever seen in the embalming room,” she said. “It was not normal.”

For Simon, that first COVID-positive body was a harbinger of things to come.

Like healthcare workers who tend to the living, last responders — medical examiners, coroners, embalmers, funeral directors and other trained mortuary workers — faced overwhelming challenges as the pandemic death toll mounted, from exploding caseloads and shortages of personal protective equipment to mental health concerns.

Unlike many other front-line workers exposed to the virus, their risk of infection was largely overlooked. Although the Centers for Disease Control and Prevention maintains the risk of contracting the virus from a dead body is low, there is no government agency tracking COVID-19 infection rates among last responders in the United States.

Workers told FRONTLINE they believe they’ve been highly exposed.

“While the body is dead, it is up to us to make sure that that body does not transmit diseases to other people,” said Dr. Dwight McKenna, coroner for Louisiana’s Orleans Parish. “We don’t know what they have until we test them,” he said.

Changing guidance from health agencies

What might seem like common knowledge now — that the virus is transmitted by respiratory droplets and smaller aerosols, tiny particles from the nose and mouth that remain suspended in the air — was often a point of contention over the past year.

It wasn’t until September, more than six months into the pandemic, that the CDC acknowledged the virus was airborne — and then reversed itself twice. Last month, the CDC again updated its guidance, emphasizing the threat of aerosols.

When asked about the changes, CDC spokesperson Dr. Sarah Reagan-Steiner said knowledge about the coronavirus is evolving. “My understanding is the basic guidance has not changed, but it has been updated as we learn more about the virus,” she said.

These updates have impacted protocols for last responders looking for guidance.

In December the CDC recognized a risk of infection for workers performing certain postmortem procedures. “Personnel who have contact with human remains, including those performing autopsy and collecting or handling specimens, are at risk for exposure to infectious agents, such as SARS-CoV-2, that may be present in tissues, blood, and other bodily fluids of the deceased person,” according to the CDC website.

Autopsies, in particular, put pathologists, coroners, technicians and medical examiners in extreme, close contact with the dead. “The pathologist is exposed to all of the contents of the human body,” said McKenna, who appears along with Simon in the documentary Death Is Our Business, a co-production of FRONTLINE, Firelight Media and WORLD Channel. “So, that’s extremely high-risk for any illness that the body may have, particularly those that are as contagious as viruses.”

The CDC recommends avoiding “aerosol-generating procedures,” such as the use of oscillating saws, which, when cutting through bone, produce a fine dust that can serve as a vector for pathogens. Routinely used during autopsies to cut through the skull and rib cage, these saws are sometimes unavoidable, Dr. James Gill, president of the National Association of Medical Examiners, wrote in an email to FRONTLINE.

“Autopsy, by its nature, is an aerosol-generating procedure,” said Gill, who added that aspirating fluids, removed from body cavities and organs, can be another source of aerosols. “Since COVID-19 is spread through the air, there is a potential for infection at autopsy.”

The Occupational Safety and Health Administration classifies the embalming and preparation of bodies with confirmed or suspected cases of COVID-19 as “high” risk. Autopsies and aerosol-generating procedures on these bodies are deemed “very high” risk. When asked how the agency determined these risk levels, a Department of Labor spokesperson pointed to the CDC’s postmortem guidance.

The CDC did not respond before publication to a question about the number of autopsies performed on COVID-19-positive bodies to date in the U.S.

Even now, not all agencies align in their risk assessment. Although the CDC says embalming may be conducted if proper precautions are taken, the World Health Organization differs sharply. “Embalming is not recommended to avoid excessive manipulation of the body,” according to the WHO.

But moving bodies is necessary, said Simon, and it can lead to the release of gas and fluids. “When we’re moving bodies from the stretcher onto the embalming table, sometimes there are a lot of secretions, bodily fluids, saliva …,” she said. “So, a lot of times we put a mask on the deceased.”

When PPE isn’t enough

The one widely reported case of a last responder contracting COVID-19 from a dead body, last year in Thailand, was later called into question by the scientific community. But various studies have shown the virus can survive in bodies postmortem, including a recent German study that found the virus remained active more than 35 hours after death. 

Dr. William Schaffner, an infectious disease specialist at the Vanderbilt University School of Medicine, said the overall risk of infection from a COVID-positive body remains minimal. While he recommended that anyone performing an autopsy wear appropriate PPE, “This is a respiratory infection,” he said. “People aren’t breathing once they’re dead.”

Both the CDC and the WHO advise workers to wear masks, gloves, goggles or face shields when working on deceased patients with known or suspected COVID-19. For autopsies and embalming, the CDC recommends workers wear fluid-resistant gowns and cut-proof gloves.

Sometimes PPE isn’t enough, said McKenna, who became infected with the virus in the first few weeks of the pandemic. “Viruses are ubiquitous,” he said. “They’re everywhere. They can get under the mask. They can get under the shield. It’s not a hundred percent, by any stretch of the imagination, no matter how many precautions you take.”

Moreover, a shortage of PPE left last responders scrambling for cover in the early months of the pandemic. “We had a real big shortage in the beginning,” said Dutch Nie, spokesperson for the National Funeral Directors Association. “All of our supply chains for PPE were being used by everyone in the country.”

When the PPE shortage eased, Nie said, some last responders found themselves vying for vaccines. They were excluded from priority access to COVID vaccines in states including Massachusetts, Nevada and Florida. “We had to lobby in individual states to get our funeral directors identified,” Nie said.

When asked why he thought funeral service workers had been discounted as essential workers, Nie pointed to social stigma. Our society is “death-averse,” he said. “There’s not a lot of discussion about it. So, we get overlooked.”

The living: still the biggest threat 

Even so, Nie said, the main source of exposure for funeral workers is the living.

As a funeral home owner in Cedar Rapids, Iowa, Peter Teahen often found himself in close contact with families. A few weeks into the pandemic, he was called to the home of someone who had died. After seeing the body, he spoke with the family. “And only then did anybody tell me that the person who died had COVID, and all the family members in the same house were positive,” he said.

Although unsure of the source, Teahen soon contracted the virus. “One of the hardest things for me to do was tell my wife I was COVID-positive,” he said, knowing too well what the virus was capable of. “I brought it home. I could have killed my wife. … How do you live with something like that?”

Last responders have faced unrelenting stress throughout the pandemic, said Teahen, who teaches counseling at the University of Iowa. He is currently doing research for a new study out of the school’s College of Public Health that looks at the pandemic’s toll on the mental health of deathcare workers. In the first phase of the study last summer, more than half of those surveyed said they experienced moderate to high levels of stress.

Teahen worries that many last responders may drop out of the field due to burnout and compassion fatigue.

“I think the impact is going to be staggering on these workers,” he said. “Nobody has paid attention to them. These people need to be listened to and cared for while they care for everybody else.”

This story is part of a co-production from FRONTLINE, Firelight Media and WORLD Channel that includes the documentary Death Is Our Business. Watch the film in its entirety below. 


Shantal Riley

Shantal Riley, Tow Journalism Fellow, FRONTLINE/Newmark Journalism School Fellowship, FRONTLINE

Twitter:

@shantalwriter

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